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Executive Summary
Community-Based Care Transition Program
Data Summary Report
May 2013 – April 2015
DENVER REGIONAL COUNCIL OF GOVERNMENTS
We make life better!
Community-based Care Transitions Program Section 3026 of the Affordable Care Act created the Community-based Care Transitions Program (CCTP) to test models for improving care transitions from the hospital to other care settings and reduce readmissions for high-risk Medicare beneficiaries. CCTP is also intended to improve the quality of medical care and document measurable savings to Medicare. Our Region’s Collaboration and Resulting CCTP Beginning in 2012, the Denver Regional Council of Governments (DRCOG), as the region’s Area Agency on Aging (AAA), began to rally a coalition of seven local hospitals and more than 50 other community service providers to establish and implement a CCTP for the Denver region. This expansive community partnership worked across the care continuum, leveraging two health systems and multiple downstream providers such as skilled nursing facilities, home health agencies, and various non-profit entities. The outcome of these efforts and partnerships resulted in DRCOG being awarded funding by CMS to implement this innovative program in the eight-county Denver metro area from April 2013 through May 2015. Our Intervention and Service Package Our 30-day program was designed to improve the quality of life for Medicare fee-for-service beneficiaries by reducing avoidable hospital readmissions and increasing their knowledge and control of their health care. Eligible patients received a home visit from a care transition coach 72 hours post-discharge that empowered them to take charge of their health care. Additionally, patients had access to non-medical supportive services needed to keep them healthy at home and avoid unnecessary hospital readmission. We achieved our results through the application of two evidence-based interventions--Dr. Eric Coleman’s care Transition Intervention (CTI), supported and measured by the Patient Activation Measure (PAM). Based on participants’ PAM scores their 30-day intervention included: • CTI coaching, • Care management services, • Transportation services, • Home-delivered meals, and • Non-medical in-home services. Project outcomes We coached more than 900 extremely high-risk patients and maintained a readmission rate that was one of the lowest in the nation. Attached you will find our final data summary with detailed results, along with a complete list of program partners.
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DENVER REGIONAL COUNCIL OF GOVERNMENTS AREA AGENCY ON AGING
COMMUNITY-BASED CARE TRANSITION PROGRAM
DATA SUMMARY REPORT
MAY 2013 – APRIL 2015
Table of Contents
Collaborative Wide
Demographic Information of Coached Patients……………………………………………….……………………..p 2
Enrollment Trends ……….…………………………………………………………………………………….……………….….p 3
Common Diagnoses of Coached Patients……………………………………………………..………….……………..p 4
Readmissions Statistics ……………………………………………………………………………………………….………p 5-6
Intervention Statistics ……….……………………………………………………………………………………………….…..p 7
Patient Activation……………………………………………………………………………………………………….…….…….p 8
Medication Discrepancies ……………………………………………………………………………………………...……...p 9
Support Services……………………………………………………………………………………….……………………….….p 10
Other Services and Supports Referrals…………………………………..……………………………………….…….p.10
Patient Flow Report………………………………………………………………….………..…….…….…………………….p 11
Post Acute Care…………………………………………………………………………………………….…………..…….p 12-14
Hospital Specific Data
St. Joseph Hospital……………………………………………………………………..…………………………………………p 16
Presbyterian / St. Luke’s Medical Center……………………………………………………………………………….p 17
Rose Medical Center……………………………………………………………………..……………………………………..p 18
The Medical Center of Aurora………………………………………………………….……………………………………p 19
Swedish Medical Center…………………………………………………………………….………………………….………p 20
Sky Ridge Medical Center…………………………………………………………………….……………………………….p 21
North Suburban Medical Center………………………………………………………………………………….………..p 22
Report Created by: Heather Kamper, LSW, Acting Transition Supervisor
[email protected] 303-480-6755
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Demographic Information of Coached Patients
Table 1
Demographic Information for CCTP Coached patients
Sex
Male
36.5%
Female
63.5% Age
0-29
0.1%
30-59
17.7%
60-79
54.6%
80-99
26.6%
100+
0.0%
Missing Data
0.9% County
Adams
7.6%
Arapahoe
34.3%
Broomfield
0.2%
Clear Creek
0.0%
Denver
43.6%
Douglas
6.6%
Jefferson
6.8%
Other
0.6%
Missing Data
0.3% Language
English
97.1%
Spanish 2.9%
Table 2
Healthcare Characteristics of CCTP Coached Patients
Length of Stay
1 day
7.7%
2 days
20.5%
3 days
20.2%
4 days
14.0%
5 days
11.4%
6 days
7.1%
7+ days
18.4%
Missing Data
0.6% Home Health upon DC
Yes
37.6%
No
53.0%
Missing Data
9.4% SNF Patients
Yes
1.5%
No
98.5%
Missing Data
0.0% Person Coached
Patient Alone 63.2%
Patient & Caregiver 31.6%
Caregiver Alone 0.8%
Missing Data 4.4%
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Enrollment Trends
By Quarter
By Month
2 8 10
29
18 16 19 27 29 31
43 52
46 37
44 51
45
78
59 68
78
59
37 33
0 10 20 30 40 50 60 70 80 90
May
-13
Jun
-13
Jul-
13
Au
g-1
3
Sep
-13
Oct
-13
No
v-1
3
Dec
-13
Jan
-14
Feb
-14
Mar
-14
Ap
r-1
4
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
CCTP Enrollment All Hospital Totals
n=919
2013 2014 2015
Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 ST. JOE’S 4 2 5 5 10 12 1 0 0
PSL 4 11 5 16 15 3 13 0 0 RMC 2 10 13 23 25 25 29 33 2
TMCA 0 27 25 15 19 20 78 79 15 SMC 0 7 9 30 32 43 52 62 16
SRMC 0 0 5 10 20 22 24 0 0
NSMC 0 0 0 4 14 15 8 0 0
TOTAL 10 57 62 103 135 140 205 174 33
Q 4 – Expansion
to SNFs, Weekend
Coverage Begins
Q 3 – SNF and HHC
Subcommittees
formed, Access to
Meditech
Q 1 – CMS
Notification of CCTP
Ending, Scaled Back
to 3 Hospitals
Q 1 - All
Hospitals
Launched
Q 2 – HealthONE Contract
Amended: Census and Direct
Access to Patients, Universal
Badges
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Common Diagnoses of Coached Patients
Chronic and Acute Medical Conditions
Diagnosis Count Percent of Patients
Hypertension 438 49%
Diabetes 223 25%
Hyperlipidemia 220 25%
Chronic Kidney Disease 206 23%
Congestive Heart Failure 167 19%
Atrial Fibrillation 150 17%
Coronary Artery Disease 143 16%
COPD 142 16%
Orthopedic Procedure 105 12%
Cancer 102 11%
Arthritis 91 10%
Pneumonia 71 8%
Sepsis 60 7%
Asthma 58 7%
Alzheimer's/Dementia 31 3%
Stroke 30 3%
Osteoporosis 29 3%
Mental Health and Substance Use
Diagnosis Count Percent of Patients
Depression 146 16%
Tobacco use 146 16%
Substance Use 52 6%
Bipolar Disorder 25 3%
Schizophrenia & Other Psychotic Disorders
18 2%
21% of patients were diagnosed
with mental health disorders
Coached Patients with Multiple
Health Conditions:
0 Conditions: 10%
1 Condition: 19%
2 Condition: 23%
3 Condition: 21%
4 Condition: 14%
5 Condition: 9%
6 Condition: 3%
7 Condition: 1%
Original Diagnosis Criteria of CCTP Based on Root Cause Analysis:
Congestive Heart Failure
COPD Sepsis
Pneumonia
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19.0% •2010 National 30-day Readmission Rate
16.2% •2010 Partner Hospitals Baseline 30-Day Readmission Rate
15.4% •2014 CCTP Nationwide Coached Patients
12.4% •2014 DRCOG CCTP Coached Patients
Readmissions Statistics
Percentage of CCTP Patients Re-hospitalized within 30 days of Hospital DC: 12.4%.
(Based on the most recent QMR data from May 2013 – October 2014)
30-Day Readmission Rate of Coached Patients by Hospital:
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5%
18%
24% 53%
Day of Readmission of CCTP Patients (n=82)
Day 0 - 3
Day 4 - 7
Day 8 - 14
Day 15 - 30
Characteristics of CCTP Patients Who Re-admitted within 30 days of Hospital DC
Average age of readmitted patients: 71.5 years
Average number of health conditions: 3 Conditions
48% of patients did not have home health care ordered upon discharge
Average LOS of index hospitalization: 3.4 Days
Average LOS of subsequent hospitalizations: 5.2 Days
On average, patients re-admitted on day: 16
87% Received a home visit
58% … and a 1st follow up call
24% … and a 2nd follow up call
16% … and a 3rd follow up call
9 8 8
6 6 6 5
4 3 3 3 3 3 3
2 2 2 2 2 2
Readmitting Diagnosis of CCTP Patients
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Intervention Statistics
Percent of CCTP Patient who Received CTI Encounters
Percent of CCTP Patient who Received Care Transitions Services
Home Visit Time Frames
Home Visit within 72 Hours of DC 40%
Home Visit after 72 Hours of DC 60%
• Hospital Visit
92%
• Hospital Visit
• Home Visit
72%
• Hospital Visit
• Home Visit
• 1st Call
53%
• Hospital Visit
• Home Visit
• 1st Call
• 2nd Call
32% • Hospital Visit
• Home Visit
• 1st Call
• 2nd Call
• 3rd Call
20%
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Patient Activation
7% of patients did not increase their PAM score
32% of patients increased their PAM score by 1 point
48% of patients increased their PAM score by 2 points
13% of patients increased their PAM score by 3 points
St. Joe's PSL RMC TMCA SMC SRMC NSMC
PAM 1 15 24 46 120 46 16 9
PAM 2 21 31 96 90 151 38 19
PAM 3 5 12 33 69 39 26 13
0
20
40
60
80
100
120
140
160 N
um
be
r o
f P
atie
nts
Coached Patients by PAM Score
32%
57%
11%
0%
Pre CCTP Patient Activation
PAM 1
PAM 2
PAM 3
PAM 4
2%
7%
34% 57%
Post CCTP Patient Activation
PAM 1
PAM 2
PAM 3
PAM 4
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Medication Discrepancies
Medication Discrepancies Found by Coaches
Total Discrepancies Counts – All CCTP Patients
0
Errors 1
Error 2
Error 3
Error 4
Error 5
Error 6
Error 7
Error n/a
Number of Patients 472 101 43 25 12 5 1 2 218
% of Patients 54% 11% 5% 3% 1% 1% 0% 0% 25%
Total Discrepancies Counts – Excluding 0 and n/a
1
Error 2
Error 3
Error 4
Error 5
Error 6
Error 7
Error
Number of Patients 101 43 25 12 5 1 2
% of Patients 53% 23% 13% 6% 3% 1% 1%
Causes and Contributing Factors
Patient Level System Level
Adverse Drug Reaction or side effects Prescribed with known allergies
Intolerance Conflicting information from different sources
Didn’t fill prescription Confusion between generic and brand names
Money/financial barriers Discharge instructions incomplete/inaccurate/illegible
Intentional non-adherence Duplication
Non-intentional non-adherence Incorrect dosage, quantity, or label
Performance deficit Cognitive impairment not recognized
No caregiver/need for assistance not recognized
Sight/dexterity limitations not recognized
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Support Services Referrals
Other Services & Support Referrals
Personal Health Records 2000
DRCOG’s Information and Assistance Flyer 1500
Advanced Directives 200
Physician Health Partners Case Management 50
NP Intern Visits 22
Chronic Disease Self Management Classes 10
All referral numbers are estimations based on coach survey and case reviews.
Number of Home Delivered Meals
Number of Transportation Rides
Number of Hours for Homemaker
Services
Care Management
ST. JOE’S 95 10 26 1
PSL 25 14 24 4
RMC 160 64 84 6
TMCA 280 74 118 12
SMC 195 54 112 7
SRMC 55 14 34 0
NSMC 90 14 16 4
All Hospital
Total 900 244 414 34
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Patient Flow Report
Aggregate Patient Flow Statistics
60% Of Medicare FFS admissions met initial eligibility criteria
29% Of patients (both eligible and ineligibly) were referred to a CCTP Coach
83% Of patients who were screened into CCTP were approached by a Coach or Case Manager
36% Of patients approached accepted CCTP services
65% Of patients who accepted CCTP services started CCTP
89% Of patients who started CCTP completed services
40
65
108
169
248
269
319
342
608
659
980
1047
1665
2802
5428
0 1000 2000 3000 4000 5000 6000
Patient Died
No Verbal Consent
Active Substance Abuse
Bone Marrow Transplant
Already Coached w/in 180 Days
Enrolled in Hosp - Unable to Reach
Language Barrier
Hospice Patient
Left Hosp Before Coach Visit - Unable to Reach
Cognitive Impairment
PAM Level 4
Refusal to Hospital CM
Refusal to Coach
Lives out of Region
D/C to SNF
Reasons Medicare FFS Patient Were Not Enrolled into CCTP
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Post Acute Care
All information in this section was obtained from CMS’s CCTP Quarterly Monitoring Report #5 for current reporting
period: October 31, 2015. The information presented in these tables was obtained from CCTP list bills as of
2/5/2015. Because of lags in list bill reporting, results for the current quarter are considered provisional. We will
update this information as we receive subsequent Quarterly Monitoring Reports.
Performance Measures for CCTP Participants
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7-Day Post-Discharge Physician Follow-Up Visit Rates
14-Day Post-Discharge Physician Follow-Up Visit Rates
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30-Day Post-Discharge Hospital Emergency Dept Visit Rates
30-Day Post-Discharge Hospital Observation Stay Rates
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Hospital Specific Data
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St. Joseph’s Hospital CCTP Data Report March 2013 – April 2015
30-Day Readmission Rate among CCTP Patients at St. Joseph’s Hospital: 16.1% (Based on the most recent QMR data from May 2013 – October 2014)
CCTP Coaches enrolled a total of 41 patients admitted to St. Joseph’s Hospital.
Among coached patients, CCTP coaches were able to identify 14 medication discrepancies.
A patient with low activation has a significant risk of readmission. The average Patient Activation Measure©
Score
increased by 1.4 points, significantly decreasing the likelihood of a 30-day readmission.
2 2
1 1
0
2 2
1
3
0
2
4
3 3 3
4
5
1
0 0 0 0 0
2
CCTP Enrollment St. Joseph's Hospital
(n=41)
141
235
6 21 10 12
60
3 6
44
147
57 29
6 2
CCTP Reasons Not Enrolled St. Joseph's Hospital
March 2013 - April 2015
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Presbyterian / St. Luke’s Medical Center CCTP Data Report May 2013 – April 2015
30-Day Readmission Rate among CCTP Patients at Presbyterian/St. Luke’s Medical Center: 10.0%. (Based on the most recent QMR data from May 2013 – October 2014)
CCTP Coaches enrolled a total of 67 patients admitted to PSL.
Among coached patients, CCTP coaches were able to identify 33 medication discrepancies.
A patient with low activation has a significant risk of readmission. The average Patient Activation Measure©
Score
increased by 1.5 points decreasing the likelihood of a 30-day readmission!
0
4 4 4 3
1 3
1 2
5
9
4 5
6
2 0
1
4 6
3
0 0 0 0
CCTP Enrollment Presbyterian / St. Luke's Medical Center
(n=67)
484 557
26 28 18 23
112 160
12
135 133 111
27 10
CCTP Referrals - Reasons Not Enrolled Presbyterian / St. Luke's Medical Center
May 2013 - April 2015
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Rose Medical Center CCTP Data Report June 2013 – April 2015
30-Day Readmission Rate among CCTP Patients at Rose Medical Center: 14.5% (Based on the most recent QMR data from May 2013 – October 2014)
CCTP Coaches enrolled a total of 175 patients admitted to Rose.
Among coached patients, CCTP coaches were able to identify 69 medication discrepancies.
A patient with low activation has a significant risk of readmission. The average Patient Activation Measure©
Score
increased by 1.7 points significantly decreasing the likelihood of a 30-day readmission!
2 3 3 4 1
6 6 6 7 10 9
5
11 10 11
4
8 8
13 16
8 9
15
CCTP Enrollment Rose Medical Center
(n=175)
942
457
95 85 35 72 165
97 3
224
411
87 51 16 6
CCTP Referrals - Reasons Not Enrolled Rose Medical Center
June 2013 - April 2015
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The Medical Center of Aurora CCTP Data Report July 2013 – April 2015
30-Day Readmission Rate among CCTP Patients at The Medical Center of Aurora: 9.8% (Based on the most recent QMR data from May 2013 – October 2014)
CCTP Coaches enrolled a total of 279 patients admitted to TMCA.
Among coached patients, CCTP coaches were able to identify 93 medication discrepancies.
A patient with low activation has a significant risk of readmission. The average Patient Activation Measure©
Score
increased by 1.5 point significantly decreasing the likelihood of a 30-day readmission!
2
15 10 11
7 7 7 2
6 7 10
2 6 6 8
30
21 27
33
24 22 16
CCTP Enrollment The Medical Center of Aurora
(n=279)
1446
321 135
267 76 75
221 194 6
300 313 182
92 28 1
CCTP Referrals - Reasons Not Enrolled The Medical Center of Aurora
July 2013 - April 2015
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Swedish Medical Center CCTP Data Report August 2013 – April 2015
30-Day Readmission Rate among CCTP Patients at Swedish Medical Center: 12.6% (Based on the most recent QMR data from May 2013 – October 2014)
CCTP Coaches enrolled a total of 236 patients admitted to Swedish.
Among coached patients, CCTP coaches were able to identify 65 medication discrepancies.
A patient with low activation has a significant risk of readmission. The average Patient Activation Measure©
Score
increased by 1.7 points, significantly decreasing the likelihood of a readmission!
6 1 1 1
7 8 11 12 14
11 7
12 18
13 20
10
22 29 27
6 0
CCTP Enrollment Swedish Medical Center
(n=236)
1569
756
44 182
67 104 197 95 25 148
360 108 68 28 20
CCTP Referrals - Reasons Not Enrolled Swedish Medical Center August 2013 - April 2015
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Sky Ridge Medical Center CCTP Data Report December 2013 – April 2015
30-Day Readmission Rate among CCTP Patients at Sky Ridge Medical Center: 13.0% (Based on the most recent QMR data from May 2013 – October 2014)
CCTP Coaches enrolled a total of 80 patients admitted to Sky Ridge.
Among coached patients, CCTP coaches were able to identify 13 medication discrepancies.
A patient with low activation has a significant risk of readmission. The average Patient Activation Measure©
Score
increased by 1.5 point significantly decreasing the likelihood of a readmission!
5
2
4 4
7
5
8 8
5
9
11 11
2
0 0 0
CCTP Enrollment Sky Ridge Medical Center
(n=81)
596
432
6 50 20 42
166
13
158 191
47 18 8 4
CCTP Referrals - Reasons Not Enrolled Sky Ridge Medical Center
December 2013 - April 2015
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North Suburban Medical Center CCTP Data Report January 2014 – April 2015
30-Day Readmission Rate among Patients at North Suburban: 13%. (Based on the most recent QMR data from May 2013 – October 2014)
CCTP Coaches enrolled a total of 41 patients admitted to North Suburban.
Among coached patients, CCTP coaches were able to identify 26 medication discrepancies.
A patient with low activation has a significant risk of readmission. The average Patient Activation Measure©
Score
increased by 1 point significantly decreasing the likelihood of a 30-day readmission!
2 2
0
7 7
0
3
7
5 4
3
1 0 0 0 0
CCTP Enrollment North Suburban Medical Center
(n=41)
262
42 10
32 16 18
63 26
120
29 27 8 2
CCTP Referrals - Reasons Not Enrolled North Suburban Medical Center
January 2014 - April 2015
